We have many different ways we can communicate with you If you would like us to communicate with you by braille, British Sign Language, a hearing loop, translations, large print, audio or something else please contact us. You can find our contact details by searching for the relevant benefit on gov.uk

If you want help filling in any part of this claim form, read the information booklet or call us on 0800 121 4600. If you have speech or hearing difficulties, you can contact us by textphone on 0800 121 4523. We can provide an interpreter if you phone or visit us.

About the child Please use BLOCK CAPITALS when completing the child’s names.

1 Surname or family name

All other names in full

Please also give us any other names the child has been known as

2 Child reference number (if you know it)

3 Date of birth (day/month/year)

4 Sex

Male □ Female □

5 Full address where the child lives

Postcode Special rules

Are you claiming for the child under the special rules? The special rules apply to children who have a progressive disease and are not expected to live longer than another 6 months.

Yes ☐ Please continue below. No ☐ Go to question 7.

Make sure you: • answer all the questions on the form that apply to you or the child you are claiming for • answer questions 25 to 36 if the child has any walking difficulties • you do not have to answer questions 37 to 55

To help us deal with the claim as quickly as possible it is important you send us a DS1500 report about the child’s medical condition. You can get the report from the child’s doctor or specialist. You will not have to pay for it and the child does not have to see the doctor. The doctor’s receptionist, a nurse or a social worker can arrange it for you.

If you have not got a DS1500 report by the time you have filled in the claim form, send the claim form anyway. If you wait the child’s payment could be delayed. Send the DS1500 report as soon as you can or ask your doctor or specialist to send it to us for you.

Getting Disability Living Allowance (DLA) under the special rules means: • the child gets the care part of DLA at the highest rate • they get paid straight away unless they are in a residential care home, boarding school or similar place • we deal with the claim more quickly

You must still tell us about any changes that may affect how much money the child gets.

What is the child’s nationality? For example, British, Spanish, Turkish If you are a Swiss or European Economic Area (EEA) national please complete the Swiss or EEA national additional question insert

Does the child normally live in Great Britain? Great Britain is England, Scotland and Wales.

Yes ☐ No ☐

Has the child come from another country to live in Great Britain in the last 3 years?

Yes ☐ No ☐ Go to question 9.

Which country did they come from?

What date did they arrive in Great Britain? / / /

Has the child been abroad for more than 4 weeks at a time in the last 3 years? Abroad means out of Great Britain.

Yes ☐ Please give us details below. No ☐ Go to question 10.

| Date they left | Date they came back | Where they went | Why they went | |----------------|---------------------|----------------|--------------| | / / / | / / / | | | | / / / | / / / | | | | / / / | / / / | | | | / / / | / / / | | | | / / / | / / / | | | | / / / | / / / | | | | / / / | / / / | | | Benefits from an European Economic Area state or Switzerland

Is the child’s parent or guardian getting any pensions or benefits from a European Economic Area (EEA) state or Switzerland?

Yes ☐ We will contact you about this. No ☐ Go to question 11.

Do not know ☐ We will contact you about this.

Other benefits from an EEA state or Switzerland

Is the child’s parent or guardian working in or paying insurance to an EEA state or Switzerland? By insurance we mean connected to work, like UK National Insurance.

Yes ☐ We will contact you about this. No ☐ Go to question 12.

Do not know ☐ We will contact you about this.

Is the child in an NHS hospital or hospice now? Or have they been admitted in the past 12 months?

Yes ☐ Please continue below. No ☐ Go to question 13.

Please tell us when they went in and when they came out.

| In | / | / | |----|---|---| | Out | / | / |

| In | / | / | |----|---|---| | Out | / | / |

Full name and address of the hospital or hospice

Phone number Include the dialling code.

Why did they go in?

Does or did the NHS fund their stay? Yes ☐ No ☐ Is the child in a residential college or similar place now, or have they been in the past 12 months? For example, a residential care home, boarding school or similar place. If the child is in a residential college or similar place when you claim we will not usually pay DLA care unless you are paying all the costs of their accommodation, board and personal care without help from a local or public authority.

Yes ☐ Please continue below. No ☐ Go to question 14.

Please tell us when they went in and when they came out.

| In | Out | |----|-----| | | |

| In | Out | |----|-----| | | |

Full name and address of where they are or were staying

Phone number Include the dialling code.

Does or did the local authority or a government department pay any costs for them to live there?

Yes ☐ Please continue below. No ☐ Go to question 14.

Which local authority or government department pays or paid?

We ask about people involved in the child’s care and may contact them before we make a decision. They do not decide if the child can get DLA.

In the last 12 months, has the child seen anyone apart from their GP about their illnesses or disabilities? For example, a hospital doctor, consultant, nurse, occupational therapist, physiotherapist, educational psychologist, social worker or support worker.

Yes ☐ Tell us below who they have seen. No ☐ Go to question 15.

If they see or have recently seen more than one health professional, it is important you tell us the other health professionals’ details at question 70 Extra information. This will help us deal with the claim more quickly.

Name For example, Mr, Mrs, Miss, Ms, Dr.

Profession or specialist area

Full address For example, health centre, hospital, office or their place of work.

Postcode Phone number Include the dialling code.

The child’s hospital record number You can find this on their appointment card or letter.

Which illness or disability do they see the child about?

When did they last see the child about their illness or disability?

Name of the child’s GP If you do not know the GP’s name, tell us the name of the surgery or health centre.

Full address

Phone number Include the dialling code.

When did they last see the child about their illness or disability?

Has the child had or are they waiting for tests to help diagnose, treat or monitor their illnesses or disabilities? For example, audiogram, MRI scan, cognitive development or IQ test, or something else.

Yes ☐ Tell us about it in the table below. No ☐ Go to question 17.

| Date and type of test | What did the test show? | |-----------------------|-------------------------| | Example | | | June 2016 Eyesight test | They needed to see a hospital doctor | Do you have any reports, letters or assessments about the child’s illnesses or disabilities? These may be from the people who treat or help them with their illnesses or disabilities. For example, doctors, health visitors or occupational therapists.

Yes ☐ Please continue below. No ☐ Go to question 18.

Tell us what reports you have. For example, educational psychologist’s report or Certificate of Vision Impairment (CVI). Please do not include things like appointment letters or general information about the child’s condition like fact sheets or information from the Internet.

Please send us this supporting information with this form, but make sure it is: • the most up-to-date information you have • photocopies only, we cannot return any documents • not on CD, DVD, memory stick or any type of electronic media as we cannot access these

Name of the child’s school or nursery

Full address

Phone number Include the dialling code.

Person we can contact For example, a teacher.

What sort of school is it? For example, a mainstream school or a special school that helps with the child’s illness or disability.

Does the child have or are they waiting to hear about an Educational Health and Care Plan (EHCP), Individual Education Plan (IEP), Individual Behaviour Plan (IBP) or statement of Special Educational Needs (statement)? In Scotland the statement is called a Co-ordinated Support Plan (CSP). If the child needs help under School Action or School Action Plus, a teacher prepares the IEP or IBP which sets out the help they need. If more help is needed, the local authority may complete an assessment and issue a letter, a Note in Lieu, or a statement.

Yes ☐ Please tick the boxes that apply. No ☐ Go to question 20.

Send us a copy, if you can, as it may help us deal with your claim. Please do not send original copies as they cannot be returned.

☐ They have an ECHP, IEP or IBP. ☐ They have a statement, Note in Lieu, letter or CSP. ☐ I am waiting to hear. Statement from someone who knows the child

This part does not have to be filled in but if it is filled in, this may help us deal with your claim more quickly. It could be filled in by someone who treats or is involved in the child’s care. For example, a health professional, a social worker or a teacher.

| Statement to be filled in by the person who knows the child. | |-------------------------------------------------------------| | Use the space below to tell us: | | • the child’s illnesses or disabilities and how they affect the child, and | | • how you help the child |

| Signature | Date | |-----------|------| | | |

| Name (please use block capitals) | |----------------------------------| | |

| Full address | |--------------| | |

| Phone number | |--------------| | Include the dialling code. |

| Job or profession | |-------------------| | |

| Relationship to child, if applicable. | |---------------------------------------| | |

| When did you last see the child? | |----------------------------------| | | / / | Sharing information about the child’s health condition

The Department for Work and Pensions (DWP) or approved healthcare professionals that work for DWP, might need more information about the child’s health condition and how it affects them. They might ask for relevant information from the child’s doctor, or any other relevant professional you tell them about.

Do you give consent for the child’s doctor or other relevant professionals to give DWP more information about their health condition?

Yes ☐ Information about the child’s health can be shared with DWP or the healthcare professionals that work for them.

No ☐ Information about the child’s health cannot be shared with DWP or the healthcare professionals that work for them.

How DWP uses this information

DWP uses this information to: • process the claim • make a decision on the claim, or any mandatory reconsideration or appeal you make

The law allows DWP to get, keep and use this information.

Your child’s doctor (or other relevant professionals you tell DWP about) needs your consent to give information to DWP. If you give your consent, this lets them know that they are legally allowed to share this information with DWP.

DWP can lawfully ask your child’s doctor, hospital consultant or other relevant professionals for information about their health condition and how it affects them. This is because we are asking for the information to help us carry out our official social security functions.

You do not have to give your consent. If you do not, DWP will make a decision based on the information they have already, as well as any you give them yourself.

If you change your mind

You can change your mind. You can do this by contacting 0800 121 4600 and say you want to give or withdraw your consent.

If you withdraw your consent, DWP cannot get information from the child’s doctor or others named on the form.

I have read and understood the text above.

Signature

Dated

/ / / The Motability Scheme

The Motability Scheme allows disabled people to lease a car, scooter or powered wheelchair in exchange for all or some of their mobility payments. Parents and carers can join the scheme on behalf of a child aged three and above.

If the child is eligible for help from Motability, would you like us to post you information about the help they can offer? We will not share any personal details with Motability.

Yes ☐ No ☐

If you decide you do not want to receive information about Motability in the future, please contact us on 0800 121 4600 to let us know.

The questions we ask and why we ask them

DLA is a benefit to help with extra costs because: • the child has difficulties walking, or • the child needs extra looking after, because of their illness or disability

By ‘extra looking after’ we mean much more than another child of the same age.

We ask about the child’s illnesses or disabilities, the treatment they have, the difficulties they have walking outdoors and the extra looking after they need.

We ask for a lot of information about the child, it may be easier to fill in the information in parts over a few days. Try not to worry about how long the form is, complete as much information about the child for each question that applies – take a break when you need to.

We understand it may be upsetting for you to think about what the child cannot do, but we need this information to make the right decision.

Tell us about the help they need most of the time. You can use the box at the end of each question to tell us: • about your tick-box answers • how their needs vary • anything else you think we should know about the help they need

If you need help to fill in the rest of the form

In the information booklet we: • explain the questions we ask • tell you how to answer the questions • give you examples of other things you can tell us

When you see you can use the information booklet to help you understand and answer the questions. About the child’s illnesses or disabilities

List the child’s illnesses or disabilities in the table below.

- **illness or disability** may be a physical, sight, hearing, speech, learning or developmental difficulty, or a mental-health problem. If they do not have a **diagnosis**, tell us their difficulty. For example, if they have problems learning new things and you do not know why, put ‘Learning problem’
- **how long** may be from birth or the date the problem started. It is not the date of diagnosis
- **treatment** may be medicines such as tablets, creams or injections and things like speech, occupational or play therapy, physiotherapy or counselling
- **how often** they have each treatment and for how long. The label on the child’s medicine has the name, dose and how often to take it

If you have a spare **up-to-date prescription list** send it to us with this claim form.

| Illness or disability | How long have they had it? | What treatment do they have for it? | How often do they have treatment? | |-----------------------|---------------------------|-----------------------------------|----------------------------------| | **Examples** ADHD | Problems started aged 4 | Cognitive behaviour therapy | One hourly session a week | | | | Ritalin 30 milligrams (mg) | One a day | | Eczema | About one year | Promethazine 5 mg | One before bed | | | | 1% Hydrocortisone cream | 3 times a day | | | | E45 Emollient bath oil | Daily | | Visually impaired | From birth | Play therapy | Every day |

If you need more space to tell us about their illnesses or disabilities, please continue at question 70

**Extra information.** Does the child use, or have they been assessed for, any aids or adaptations?

Yes ☐ Please continue below.\
No ☐ Go to question 24.

Tell us in the table below about any:

- aids used at home, at school or anywhere else
- aids or adaptations they have been assessed for or are waiting for
- help they need to use it. This could be encouragement, prompting or physical help

Put a tick next to the aid or adaptation if it was prescribed by a health care professional. For example, an occupational therapist.

Use page 5 of the information booklet.

| Aids and adaptations | ✓ | What help do they need to use the aid or adaptation? | |----------------------|---|-----------------------------------------------------| | Example of aid | ✓ | Encouragement to use cards to communicate | | Picture Exchange Cards| | | | Example of adaptation | | No help needed | | Bed rails | | |

If you need more space to tell us about their aids or adaptation, please continue at question 70 Extra information. When the child needs help

We understand the help a child needs can vary from day to day or week to week. To make the right decision, we need to know if the help the child needs is the same most of the time or varies.

Tick the box below that applies to them.

The help they need:

- is the same most of the time
- varies

Tell us in the box below how their needs vary.

For example:

- every 3 to 4 weeks they have a couple of good days
- they need more looking after when their condition gets worse, 2 to 3 times a year, or
- they have treatment 3 times a week and need more looking after the day after

Mobility questions

Mobility – these questions are about the difficulty that the child has walking outdoors because of their illnesses or disabilities.

Questions 25 to 31 are about the physical difficulties a child has walking. This is for children age 3 and over.

Questions 32 to 34 are about the guidance and supervision they need when walking outdoors most of the time. This is for children age 5 and over.

The following questions ask about ‘they’. This means the child you are claiming DLA for.

Mobility

These are about their ability to physically walk outdoors on a reasonably flat surface. We cannot consider any problems they have walking on steps, slopes or uneven ground. If their problems are not physical, do not answer questions 25 to 31. Tell us about any behavioural difficulties with walking at questions 32 to 34.

Can they physically walk?

Tick No if they cannot walk at all.

Yes Go to question 26.

No Go to question 36 to tell us how long they have been unable to walk.

Do they have physical difficulties walking?

This means problems with how far they can walk, how long it takes, their walking speed, the way they walk, or the effort of walking and how this may affect their health.

Yes Go to question 27.

No Go to question 32. Please tick the boxes that best describe how far they can walk without severe discomfort and how long it takes them.

This means the total distance they can walk before they stop and cannot go on because of severe discomfort. This may include short stops to catch their breath or ease pain.

We understand this can be difficult to work out.

It may help to do the following things when you are out walking with the child:

• count the steps you take to see how far they have walked. If they walk 100 of your steps, they have walked about 90 metres (100 yards) • check the time when you start and stop to see how long it takes

Use page 5 of the information booklet.

They can walk:

• over 200 metres (218 yards) • 51 to 200 metres (56 to 218 yards) • 50 metres (55 yards) or less • a few steps

It takes them:

• more than 5 minutes • 3 to 4 minutes • 1 to 2 minutes • less than a minute

Please tick the box that best describes their walking speed.

Normal This means they can easily keep up with friends.

Slow This means they can only keep up with friends with a lot of effort.

Very Slow This means they cannot keep up with friends. Please tick the box that best describes the way they walk.

They:

- walk normally
- walk with a limp
- shuffle
- drag their leg
- walk with one or both feet turned inwards
- walk on their toes
- have poor balance

If they have other difficulties with the way they walk, tell us below what they are.

Does the effort of walking seriously affect their health?

For example, walking can cause bleeding into the knee and ankle joints.

Yes □ Tell us below how their health is affected. No □ Go to question 31.

If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.

For example, they have more pain or tiredness if they walk too far the day before. Do they need guidance or supervision most of the time when they walk outdoors?

Use page 6 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 33.

Can they:

- find their way around places they know? ☐ ☐
- ask for and follow directions? ☐ ☐
- walk safely next to a busy road? ☐ ☐
- cross a road safely? ☐ ☐
- understand common dangers outdoors? ☐ ☐

Do they regularly:

- become anxious, confused or disorientated? ☐ ☐
- display unpredictable behaviour? ☐ ☐
- need physical restraint? ☐ ☐

Do they fall due to their disability?

Yes ☐ Please continue below. No ☐ Go to question 34.

Tell us the number of falls each month

They:

- can get up without help ☐ ☐
- have had injuries needing hospital treatment ☐ ☐

If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.

For example, they are frightened by loud noises and behave without thinking about danger. Extra information about mobility

If you want to tell us anything else about their mobility, use the box below.

When did the child’s mobility needs you have told us about start?

Normally, the child can only get the mobility part of DLA if they have needed help for more than 3 months.

Please tell us the date the mobility needs you have told us about started.

/ /

If you cannot remember the exact date, tell us roughly when this was.

If you are claiming under the special rules, go straight to question 56. Care questions

Care – these questions are about the extra looking after that the child needs because of their illnesses or disabilities. These questions are for children of all ages.

Questions 37 to 52 are about the help they need during the day.

For example, if a child gets up at 7am and goes to bed at 8pm and the parents get up at 7am and go to bed at 11pm, day time would be 7am to 11pm. Any help needed after 11pm would count as help during the night.

The following questions ask about ‘they’. This means the child you are claiming DLA for.

Care

37 Do they need encouragement, prompting, or physical help to get into or out of or settle in bed during the day?

This means waking up, lifting their legs into or out of bed, sitting up from lying down or settling in bed ready to go to sleep.

Use page 7 of the information booklet.

Yes ☐ Please continue below. No ☐ Go to question 38.

Tell us how often they need help each day and how long it takes each time.

| They need encouragement, prompting or physical help to: | How often each day? | How long each time? | |--------------------------------------------------------|---------------------|---------------------| | • wake up | | minutes | | • get out of bed | | minutes | | • get into bed | | minutes | | • settle in bed | | minutes |

If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.

For example, they may need to follow a set routine to go to or get out of bed. Do they need encouragement, prompting, or physical help to go to or use the toilet during the day? This means going to the toilet, managing their clothes, getting on and off the toilet, using the toilet, cleaning themselves and coping with continence care.

Use page 7 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 39.

They need encouragement, prompting or physical help to:

- go to the toilet ☐
- manage clothes ☐
- get on and off the toilet ☐
- wipe themselves ☐
- wash and dry their hands ☐
- manage a catheter, ostomy or stoma ☐
- manage nappies or pads ☐

If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below. For example, they have pain and become distressed. Do they need encouragement, prompting, or physical help to move around indoors, use stairs or get into or out of a chair during the day?

A chair is any type of chair including a wheelchair. This means moving from one place to another, using stairs, getting into, sitting in, and getting out of a chair. Indoors is in their home, a friend’s home, school, college, or anywhere else inside.

Use page 8 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 40.

They need encouragement, prompting or physical help to:

• go up and down one step ☐ • go upstairs ☐ • go downstairs ☐ • move around safely ☐ • get into or out of a chair ☐ • sit in a chair ☐

If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.

For example, they bump into furniture and doors. Do they need encouragement, prompting, or physical help to wash, bath, shower and check their appearance during the day. This means getting in and out of a bath or shower, washing their hair, drying themselves, using soap, using a toothbrush and checking their appearance.

Use page 9 of the information booklet.

Yes ☐ Please continue below. No ☐ Go to question 41.

Tell us how often they need help each day and how long it takes each time.

| They need encouragement, prompting or physical help to: | How often each day? | How long each time? | |--------------------------------------------------------|---------------------|---------------------| | • have a wash | | minutes | | • clean their teeth | | minutes | | • wash their hair | | minutes | | • get in or out of the bath | | minutes | | • get in or out of the shower | | minutes | | • clean themselves in the bath or shower | | minutes | | • dry themselves after a bath or shower | | minutes | | • check their appearance | | minutes |

If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below. For example, when they are in the bath they need telling repeatedly what to do and how to do it. Do they need encouragement, prompting, or physical help to dress and undress during the day? This means choosing the right clothes for the weather or activity, choosing clean clothes, putting clothes on in the correct order, moving their arms or legs to put clothes on or take them off. This is any dressing or undressing except when using the toilet.

Use page 10 of the information booklet.

Yes ☐ Please continue below. No ☐ Go to question 42.

Tell us how often they need help each day and how long it takes each time.

| They need encouragement, prompting or physical help to: | How often each day? | How long each time? | |--------------------------------------------------------|---------------------|---------------------| | • dress | | minutes | | • undress | | minutes | | • manage zips, buttons or other fastenings | | minutes | | • choose appropriate clothes | | minutes |

If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below. For example, they follow a set routine that takes a long time.

Do they need encouragement, prompting, or physical help to eat and drink during the day? This means getting food into their mouth, chewing, swallowing, using cutlery, cutting up food, holding a cup, getting it to their mouth and drinking.

Use page 10 of the information booklet.

Yes ☐ Please continue below. No ☐ Go to question 43. Tell us how often they need help each day and how long it takes each time.

| They need encouragement, prompting or physical help to: | How often each day? | How long each time? | |--------------------------------------------------------|---------------------|---------------------| | • eat | | minutes | | • use a spoon | | minutes | | • cut up food on their plate | | minutes | | • drink using a cup | | minutes | | • be tube or pump fed | | minutes |

If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.

For example, they cannot see what food is on the plate.

______________________________________________________________________

Do they need encouragement, prompting, or physical help to take medicine or have therapy during the day?

Taking medicine includes tablets, injections, eye drops, knowing what to take, how much to take and when to take it.

Having therapy includes blood sugar testing, peak flow checks, physio, oxygen, speech, play and behaviour therapy, knowing what to do, how much to do and when to do it.

Use page 11 of the information booklet.

Yes ☐ Please continue below.\
No ☐ Go to question 44.

Tell us how often they need help each day and how long it takes each time.

| They need encouragement, prompting or physical help to: | How often each day? | How long each time? | |--------------------------------------------------------|---------------------|---------------------| | • take the correct medicine | | minutes | | • know when to take their medicine | | minutes | | • do their therapy | | minutes | | • know when to do their therapy | | minutes | If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.

For example, they become angry with their condition and refuse to take their medicine.

______________________________________________________________________

**Do they have difficulty seeing?**

This means when using their aids like glasses or contact lenses.

Use page 12 of the information booklet.

Yes ☐ Please continue below.\
No ☐ Go to question 45.

**Are they certified sight impaired or severely sight impaired?**

If they are certified they will have been examined at a hospital or eye clinic.\
A Certificate of Vision Impairment (CVI) will have been sent to the local social services department. You will have been given a copy.\
If they are certified, please send us a copy of the CVI. Please do not send original copies as they cannot be returned.

Certified severely sight impaired ☐ Go to question 45.\
Certified sight impaired ☐ Tick the boxes that apply.

They can see:

- computer keyboard keys or large print in a book
- a TV and follow the actions to a story
- the shape of furniture in a room

They can recognise:

- someone’s face across a room
- someone across a street

______________________________________________________________________

If you want to tell us more about the boxes you have ticked, how their needs vary or anything else you think we should know, use the box below.

For example, they have difficulty seeing in poorly lit places like a cinema.

______________________________________________________________________

**45 Do they have difficulty hearing?**

This means hearing sound or someone speaking when using their hearing aid.

Use page 12 of the information booklet.

______________________________________________________________________

**Yes** [ ] Tick the boxes that apply.\
**No** [ ] Go to question 46.

______________________________________________________________________

**Have they had an audiology test in the last 6 months?**

If you send us a photocopy of the report it may help us deal with the child’s claim. Please do not send original copies as they cannot be returned.

They can hear:

- a whisper in a quiet room
- a normal voice in a quiet room
- a loud voice in a quiet room
- a TV, radio or CD but only at a very loud volume
- a school bell or car horn

______________________________________________________________________

If you want to tell us more about the boxes you have ticked, how their needs vary or anything else you think we should know, use the box below.

For example, they cannot hear things if there is a lot of background noise. Do they have difficulty speaking? This means the ability to say words out loud and talk clearly.

Use page 13 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 47.

They can:

- speak clearly in sentences ☐ ☐
- put words together to make simple sentences ☐ ☐
- speak single words ☐ ☐

They can communicate using speech:

- with someone they know ☐ ☐
- with someone they do not know ☐ ☐

If you want to tell us more about the boxes you have ticked, how their needs vary or anything else you think we should know, use the box below. For example, they get embarrassed about the way they talk and will only speak to people they know.

______________________________________________________________________

Do they have difficulty and need help communicating? This means passing on information, asking and answering questions, telling people how they feel, giving and following instructions.

Use page 14 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 48.

To communicate they use:

- writing ☐ ☐
- BSL (British Sign Language) ☐ ☐
- lip-reading ☐ ☐
- using hand movements, facial expressions and body language ☐ ☐
- Makaton ☐ ☐ If they use another form of communication, tell us below what it is. This could be Sign Supported English (SSE), Signed English (SE), Finger Spelling, Picture Exchange Communication System (PECS), Tadoma or something else.

They can communicate:

- with someone they know
- with someone they do not know

If you want to tell us more about the boxes you have ticked, how their needs vary or anything else you think we should know, use the box below.

For example, they may be at risk because they do not understand a warning.

Do they have fits, blackouts, seizures, or something similar? This means epileptic, non-epileptic or febrile fits, faints, absences, loss of consciousness and ‘hypos’ (hypoglycaemic attacks).

Use page 15 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 49.

Tell us what type they have and what happens

They:

- can recognise a warning and tell an adult

- can recognise a warning and take appropriate action

- have no warning

- have had a serious injury in the last 6 months because of a fit, blackout or seizure

- display dangerous behaviour after a fit, blackout or seizure Tell us:

- the number of days affected each month

- how many fits they have on these days

- the number of nights affected each month

- how many fits they have on these nights

**Have they had an episode of status epilepticus in the past 12 months?** This is where there is persistent epileptic activity for more than 30 minutes, or they have several seizures without becoming conscious between each seizure.

Yes [ ] No [ ]

If you want to tell us more about the boxes you have ticked, how their needs vary or anything else you think we should know, use the box below. For example, they become distressed and need reassurance.

______________________________________________________________________

**Continue at question 70 if necessary.**

**Do they need to be supervised during the day to keep safe?** This means they need someone to keep an eye on them because of how they feel or behave, or how they react to people, changing situations and things around them.

Use page 16 of the information booklet.

Yes [ ] Tick the boxes that apply. No [ ] Go to question 50.

Can they:

- recognise and react to common dangers? [ ] [ ]

- cope with planned changes to daily routine? [ ] [ ]

- cope with unplanned changes to daily routine? [ ] [ ] Do they regularly:

- feel anxious or panic?

- become upset or frustrated?

- harm themselves or others?

- feel someone may harm them?

- become verbally or physically aggressive or destructive?

- act impulsively?

- have tantrums?

If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.

For example, they behave without thinking about dangers or how it will affect others.

______________________________________________________________________

Do they need extra help with their development?

This means any extra help they need to improve their understanding of how to behave and react to people, situations and things around them.

Use page 16 of the information booklet.

______________________________________________________________________

Yes\
No

Tick the boxes that apply.

They need help to:

- understand the world around them
- recognise their surroundings
- follow instructions
- play with others
- play on their own
- join in activities with others
- behave appropriately
- understand other people’s behaviour If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.

For example, they may have difficulty making friends.

______________________________________________________________________

**51**

Do they need encouragement, prompting or physical help at school or nursery?

Use page 17 of the information booklet.

Yes ☐ Tick the boxes that apply. No ☐ Go to question 52.

They need encouragement, prompting or physical help to:

- go to and use the toilet ☐ ☐
- safely move between lessons ☐ ☐
- change into different clothes for physical education and other school activities ☐ ☐
- eat meals ☐ ☐
- take medicine or do their therapy ☐ ☐
- communicate ☐ ☐

What extra help do they need with learning?

______________________________________________________________________

What is their behaviour like at school or nursery?

______________________________________________________________________

How do they usually get to and from school or nursery? If you want to tell us more about the boxes you have ticked, how their needs vary or anything else you think we should know, use the box below.

For example, they have one-to-one help from a teaching assistant.

______________________________________________________________________

Do they need encouragement, prompting or physical help to take part in hobbies, interests, social or religious activities?

Use page 18 of the information booklet.

Yes ☐ Please continue below. No ☐ Go to question 53.

Tell us:

• what they do or would do if they had help • what help they need or would need to do this • how often they do it or would do it if they had the help, and • how long they need or would need help each time

At home

| Activity | Help needed | How often? | How long each time? | |----------|-------------|------------|---------------------| | Example | | | | | Art | Encouragement to get paints, brushes and paper. Motivate to keep interested. Help to wash hands afterwards. | 2 times a week | One hour |

______________________________________________________________________

Please continue below. When they go out

| Activity | Help needed | How often? | How long each time? | |----------|-------------|------------|---------------------| | Example | Swimming | To get changed, to get in and out of the pool, to dry themselves. | Once a week | 45 minutes |

Do they wake and need help at night, or need someone to be awake to watch over them at night?

Question 53 is about the help needed during the night.

Night is when everyone in the house is in bed. For example, if a child goes to bed at 8pm and the parents go to bed at 11pm, night would start at 11pm. Any help needed before 11pm would count as help during the day.

Use page 19 of the information booklet.

Yes ☐ Please continue below.\
No ☐ Go to question 54.

Tell us how often each night they need help and how long it takes each time.

They need encouragement, prompting or physical help to:

- get into, get out of or turn in bed
- get to and use the toilet, manage nappies or pads
- have treatment
- settle or re-settle

| Help needed | How often each night? | How long each time? | |-------------|-----------------------|---------------------| | | | minutes |

They need watching over because they:

- are unaware of danger and may harm themselves or others
- may wander about
- have behavioural problems

| Help needed | How often each night? | How long each time? | |-------------|-----------------------|---------------------| | | | minutes | If you want to tell us why they need help or watching over, how their needs vary or anything else you think we should know, use the box below.

For example, they do not sleep regular hours each night.

Extra information about care

If you want to tell us anything else about their care needs, use the box below.

When did the child’s care needs you have told us about start?

Normally, the child can only get the care part of DLA if they have needed help for more than 3 months.

Please tell us the date the care needs you have told us about started.

/ / /

If you cannot remember the exact date, tell us roughly when this was. About you

Use this page to tell us about yourself, not the child.

56 Your surname or family name

All other names in full

Title For example, Mr, Mrs, Miss, Ms

57 Your date of birth

58 Your National Insurance number

Letters Numbers Letter

59 Address if different to the child’s

Postcode

60 If you live in Wales and would like us to contact you in Welsh, tick this box.

61 Your daytime phone number where we can contact you or leave a message.

Phone number Include the dialling code.

Mobile phone number, if different.

If you have speech or hearing difficulties and want us to contact you by textphone, please tick this box.

Textphone number

62 What is your relationship to the child?

63 What is your nationality?

64 What is the Child Benefit number for the child? About Income Support

65 Are you getting or waiting to hear about Income Support?

No ☐ Yes ☐

66 Is anyone within your household getting or waiting to hear about Income Support?

No ☐ Yes ☐ Please tell us their name:

Their National Insurance number:

Letters Numbers Letter

Their relationship to you:

About tax credits

67 Is anyone within your household getting or waiting to hear about Child Tax Credit?

No ☐ Yes ☐ Please tell us their name:

Their National Insurance number:

Letters Numbers Letter

Their relationship to you:

68 Is anyone within your household getting or waiting to hear about Working Tax Credit?

No ☐ Yes ☐ Please tell us their name:

Their National Insurance number:

Letters Numbers Letter

Their relationship to you: How we pay you

Please tell us your account details below.

You must read pages 19 and 20 of the information booklet before you fill in the account details.

It is very important you fill in all the boxes correctly, including the building society roll or reference number, if there is one. If you tell us the wrong account details, the payment may be delayed or the child may lose money.

Name of the account holder Please write the name of the account holder exactly as it is shown on the debit card, statement or chequebook.

Full name of bank or building society

Sort code Please tell us all 6 numbers, for example: 12-34-56.

Account number Most account numbers are 8 numbers long. If your account number has fewer than 10 numbers, please fill in the numbers from the left.

Building society roll or reference number If you are using a building society account you may need to tell us a roll or reference number. This may be made up of letters and numbers, and may be up to 18 characters long. If you are not sure if the account has a roll or reference number, ask the building society.

You may be getting other benefits and payments we do not pay into an account. If you want us to pay them into the account above, please tick this box. Extra information

Tell us anything else you think we should know about the child’s claim.

If you need more space continue on a separate piece of paper. Please put the child’s name and date of birth on any extra pieces of paper you send us. Declaration

We cannot pay any benefit until you have signed the declaration and returned the form to us. Please return the signed form as soon as you have completed it.

I declare the information I have given on this form is correct and complete as far as I know and believe.

I understand that if I knowingly give false information, my benefit may be stopped and I may be liable to prosecution or other action.

I understand that I must promptly tell the office that pays the child’s Disability Living Allowance of anything that may affect my entitlement to, or the amount of, that benefit.

I understand that the Department for Work and Pensions may use the information which it has now or may get in the future to decide whether I am entitled to:

• the benefit I am claiming for the child • any other benefit I have claimed • any other benefit I may claim or be awarded in the future

This is my claim for Disability Living Allowance.

Signature

Date

Print your name here

Send the claim form and the documents listed above back to us straight away in the envelope we have sent you. It does not need a stamp. You can send more information to us at any time.

How DWP collects and uses information

When we collect information about you we may use it for any of our purposes. These include:

• social security benefits and allowances • child maintenance • employment and training • investigating and prosecuting tax credits offences • private pensions policy and • retirement planning

We may get information about you from other parties for any of our purposes as the law allows to check the information you provide and improve our services. We may give information about you to other organisations as the law allows, for example to protect against crime.

To find out more about our purposes, how we use personal information for those purposes and your information rights, including how to request a copy of your information, please visit www.gov.uk/dwp/personal-information-charter What to do now

Check you have filled in all the questions that apply to you or the child you are claiming for:

- check you have included full details of your GP at question 15
- included full details for anyone else you have seen at question 14
- you have ticked the relevant box and signed the consent at question 21
- you have given us any extra information at question 70
- if your claim is going to be late getting to us, you tell us the reason at question 70
- you have signed the declaration at question 71
- check the person whose details are in About You at question 56 is the person who signs the consent and declaration

Make sure you have given as much information as you can.

Read pages 3 to 6 of the information booklet about how we collect and use information and for help and advice about other benefits.

List below all the supporting information you are sending with this claim form. For example, a prescription list, medical report or a statement of Special Educational Needs.

Only send photocopies of up-to-date supporting information you already have as we cannot return any originals.

Please do not include things like appointment cards or general information about the child’s condition like fact sheets or information from the Internet.